Provider Demographics
NPI:1033523485
Name:BAKUS, KEEGAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEEGAN
Middle Name:
Last Name:BAKUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 LAFOLLETTE STA S
Mailing Address - Street 2:
Mailing Address - City:FLOYDS KNOBS
Mailing Address - State:IN
Mailing Address - Zip Code:47119-9780
Mailing Address - Country:US
Mailing Address - Phone:812-923-8871
Mailing Address - Fax:812-923-8872
Practice Address - Street 1:411 LAFOLLETTE STA S
Practice Address - Street 2:
Practice Address - City:FLOYDS KNOBS
Practice Address - State:IN
Practice Address - Zip Code:47119-9780
Practice Address - Country:US
Practice Address - Phone:812-923-8871
Practice Address - Fax:812-923-8872
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN12012133A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program